The modern state is being reshaped by multiple forces acting simultaneously. From above, the state is actively constrained by agreements promoted by international agencies and by the power of multinational corporations. From within, the state is being reshaped by increasing trends toward marketization and by problems of corruption. From below, the state's role is being diminished by the expansion of decentralization and by the rising influence of non–governmental organizations. This article explores these three sets of processes — from above, from within, and from below — and suggests some implications for public health. Public health professionals require an understanding of the changing nature of the state, because of the consequences for thinking about the metaphors, solutions, and strategies for public health.