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Pedestrians wears masks as they wait for the crosswalk to change, in Edmonton on Nov. 24, 2020.JASON FRANSON/The Canadian Press

Medicine Hat, Alta., is the only major city in Canada with no mandatory mask law, according to Mayor Ted Clugston. Every other province has a mask mandate, and every major centre in Alberta has its own bylaw. And Mr. Clugston is fine – for the moment – with his city being an outlier.

He worries that masks give people a false sense of security about getting close to others, and notes that 80 to 90 per cent of Medicine Hat residents are already wearing face coverings in public. Allowing people the freedom of choice is important to him: Keeping the peace between groups calling for a lockdown and those who think the disease is a hoax has become a non-stop political balancing act.

And up until the beginning of November, you could count the number of active cases on one hand in the city of 65,000. “I don’t believe the community needs it,” he said this week.

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But the situation has shifted dramatically this month. Up until now in Alberta, COVID-19 has mostly been a health crisis in the province’s two largest cities. Areas outside of Calgary and Edmonton still don’t have comparable infection counts, measured at a rate of cases per 100,000 people, to the urban areas. But smaller communities are increasingly at risk.

“We’ve had, unfortunately, introductions in different parts of the province,” Deena Hinshaw, Alberta’s Chief Medical Officer of Health, said Friday. “We have seen many different municipalities across the province moving into that threshold where they are experiencing more than 50 active cases per 100,000.”

The growth rates of active COVID-19 cases in the provincial health zones that cover rural areas and smaller centres are now similar to what is being seen in Calgary and Edmonton. And there are alarming increases in Alberta towns and Indigenous communities, sometimes located far away from major hospitals with ICU beds and ventilators, and often with more elderly populations.

The large First Nations community of Maskwacis just south of Edmonton has seen a rapid spread in the past month. The case numbers “blew up” in October, said Randy Littlechild, executive director of Maskwacis Health Services. Coronavirus spread at funerals and Thanksgiving gatherings contributed to a fivefold increase in cases over a month – going from 30 active cases on Oct. 25 to 152 active cases on Nov. 27. In some instances, communities are seeing COVID-19 for the very first time. Stanley Delorme, chairman of the Buffalo Lake Métis Settlement northeast of Edmonton – with a population of about 700 – said the community found its first two cases of COVID-19 this week.

Outside of Calgary and Edmonton, there’s some resistance to public-health orders that feel divorced from local realities of low case counts, such as the decision to ban most indoor social gatherings. There’s also concern from local leaders who feel they don’t have the resources or the authority to enforce public-health measures.

And so far, many smaller communities have suffered more from the loss of jobs and businesses in the pandemic than the disease itself. Part of Alberta’s United Conservative Party government’s reasoning for not imposing stricter provincial restrictions, as many doctors have pleaded for, is to protect livelihoods in those communities.

The increasing cases outside of major centres in Alberta is similar to trends seen elsewhere. In Quebec, for instance, the second wave has been more rural than urban, by some measures. While Montreal’s long-term care homes saw the worst devastation in the spring, cases this fall have soared in outlying regions like the Lanaudière north of Montreal and the Gaspé peninsula.

The Estrie, a farming and mining area east of Montreal, was hailed as a COVID success story as recently as Halloween, before seeing infections spike in November. It has now joined Quebec’s big cities in the “red zone,” the highest level in the province’s pandemic alert system.

The second wave is coming, and attitudes are shifting. Medicine Hat, for instance, now has just more than 100 active cases. Mr. Clugston and his council are keeping a close eye on the “fluid” situation, and he acknowledges they might have to change tack.

He said his city’s path would have been made easier if the province had made some kind of mask-wearing mandatory across Alberta this week, as many expected. But Premier Jason Kenney laid out why his government decided against more stringent public-health orders in a Facebook question-and-answer session.

“There are large swaths of the province, in rural Alberta, where there is no significant case spread,” Mr. Kenney said Wednesday.

“Imagine you got a couple guys working in a big barn, way up in the Municipal District of Opportunity, you know, hundreds of kilometres away from the closest COVID hot zone. Do you really think those guys are going to put on a mask because I ask them to, or tell them to? Do you think the RCMP is going to go out there and write a ticket if they’re not?”

Mr. Kenney said he will continue to encourage face-covering, but doesn’t want to create a backlash. He said a rural MLA told him mask-wearing rates in his constituency are increasing, but “a lot of these folks who are doing that now, they’d take it off the moment the government tells them to wear it.”

The Opposition NDP said the Premier’s remarks show political cowardice. “This Premier is fixated on placating fringe members of his party, and he’s putting everyone else’s health at risk in the process,” health critic David Shepherd said in a news release.

Edmonton infectious-disease physician Leyla Asadi said while she understands the pandemic has presented a challenging situation for political leaders, difficult choices must be made.

“The challenge of public health is convincing people that they need to do or change something before anything bad has happened to them,” Dr. Asadi said. “I wish we could somehow help people understand that COVID-19 is an exceptionally serious illness that has put Alberta’s hospitals into crisis.”

She added the virus is going to soon become a lot more real for many more Albertans. As the virus spreads, there will be less difference between what is happening in the province’s larger and smaller communities.

The response to the virus everywhere is complicated by difficult economic circumstances on the ground. In Medicine Hat, Mr. Clugston said a spate of suicides amongst young men this year, and the closing of small businesses have so far caused more grief in his community than COVID-19 infections.

“I get a paycheque on the 1st and 15th, whether or not I show up. They don’t,” Mr. Clugston said of small-business owners. “I have heard the tears from business owners. They’re losing everything they have.”

Charlie Cutforth, chief administrative officer for Ponoka County, said he’s been in his job for more than three decades, and he’s now frightened by how the pandemic has hit local restaurants and shops, along with the increasing mental-health issues in his community. “I’ve never seen anything like it.”

Mr. Cutforth also said he’s not sure a provincewide mask mandate would influence the number of people wearing face coverings. The province promised Friday to boost enforcement capability, but the county as of now has just one peace officer on staff. “It’s easy to pass a rule and make a regulation. It’s a son-of-a-gun to enforce.”

It was difficult for county residents to take COVID-19 seriously in the recent summer months, when there were no cases in the area, Mr. Cutforth added. And there has never been the same level of concern as in Edmonton or Calgary. But now cases are rising, and it has the attention of many community members, he said.

“People have to see it to believe it.”

With a file from Eric Andrew-Gee

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